Summaries of health policy coverage from major news organizations

Anthem Criticized For Denying Claims For Patients Who Go To ER For ‘Non-Emergency’ Ailments

Patients, doctors and hospitals have been publicly criticizing the insurer over the tactic. Anthem says its policy aims to reduce use of emergency departments to rein in health care costs. In other marketplace news: The Wall Street Journal examines the behind-the-scenes role of Ramesh “Sunny” Balwani at Theranos, while other news outlets cover Aetna, CVS Caremark, Cigna and Express Scripts.

The New York Times:
As An Insurer Resists Paying For ‘Avoidable’ E.R. Visits, Patients And Doctors Push Back
Anthem denied thousands of claims last year under its “avoidable E.R. program,” according to a sample of emergency room bills analyzed by the American College of Emergency Physicians. The program, which Anthem has been rolling out in a handful of states in recent years, reviews claims based on the final diagnosis of patients. Emergency room physicians say that, last year, the company did not routinely request medical records for denied patients, and therefore could not review the symptoms that brought them to the emergency room. Anthem says it is now reviewing such records before issuing denials. (Abelson, Sanger-Katz and Creswell, 5/19)

The Wall Street Journal:
Theranos Inc.’s Partners In Blood
Much of the attention has focused on Theranos founder Elizabeth Holmes. But another character played a central role behind the scenes in the alleged fraud: Ms. Holmes’s boyfriend, Ramesh “Sunny” Balwani, according to more than three dozen former Theranos employees who interacted with Mr. Balwani extensively over a number of years. Mr. Balwani, who met Ms. Holmes when she was a teenager, jointly ran the company with her for seven years as president and chief operating officer and enforced a corporate culture of secrecy and fear until his departure in the spring of 2016, the former employees say. Unlike Ms. Holmes and Theranos, who reached a settlement with the SEC to resolve the agency’s civil charges in March without admitting or denying wrongdoing, Mr. Balwani has denied separate charges the SEC filed against him in a parallel action and is fighting them in a California federal court. (Carreyrou, 5/18)

Stat:
ALS Patients Losing Time As They Wait For Insurers To Cover Pricey New Drug
Like an untold number of ALS patients, [Sarah] Benoit faces a conundrum. She can’t afford the $145,000 price of the drug without insurance, but her insurance provider has repeatedly denied access to the drug, even though it was approved by the Food and Drug Administration last fall for all ALS patients. And as time goes by, Benoit knows that she is losing a chance to delay the inevitable. ... Certainly, there is nothing new about a high-priced medicine or insurers acting as impenetrable gatekeepers. In this case, the manufacturer of Radicava, MT Phrama, maintains that years of research expense must be recovered. And for their part, various insurers argue that coverage decisions, while nuanced, reflect legitimate criteria. (Silverman, 5/21)

Stat:
Aetna Pressures Whistleblower Who Alleged CVS Caremark Ripped Off Medicare
Aetna wants an employee to return or destroy documents that formed the basis of a whistleblower lawsuit she filed against CVS Caremark, alleging that the pharmacy benefit manager improperly reported generic drug prices to the federal government, according to a source familiar with the matter. At the same time, CVS Caremark is seeking to redact key portions of the lawsuit, which is currently under seal, before it is made available to the public (although you can read it here). The lawsuit, which STAT first reported last month, revolves around the complicated contracts between pharmacy benefit managers and Medicare Part D plans, as well as the pricing that must be reported to the Centers for Medicare and Medicaid Services. (Silverman, 5/18)

Modern Healthcare:
How Cigna And Express Scripts Decided To Merge Amid Anthem Drama
Fresh from a break up with rival and former merger partner Anthem in May 2017, health insurer Cigna Corp. wasted no time searching for a rebound. It ended up pursuing the nation's No. 1 pharmacy benefit manager, Express Scripts, which was at the time concerned with its future as a stand-alone PBM after losing Anthem as its biggest client. Bloomfield, Conn.-based Cigna and Express Scripts filed a preliminary registration statement with the Securities and Exchange Commission on Wednesday detailing the terms of their merger agreement, announced in early March. (Livingston, 5/17)

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